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Rhinoplasty and Nasal
Fracture Surgery
Grant S. Gillman
There is no single rhinoplasty operation, and for that reason the learning curve is a long and steep one. This chapter will attempt to highlight some of the more fundamental surgical maneuvers and concepts in basic rhinoplasty and nasal fracture surgery to serve as a basis on which one can build.
- Timing of surgery Invariably, patients are told to see the ear, nose, and throat specialist “once the swelling is all gone.” Two problems can result from that approach. First, the diagnosis of a septal hematoma or abscess may be inadvertently delayed. Second, the patient may not show up for 10 to 12 days, at which point the need to intervene becomes more pressing, and the ability to “plan ahead” is lost. It is better to see patients early (within 3 days of injury) so that serious complications are recognized. If a closed reduction is felt to be necessary, there is then adequate time to work the case into one’s schedule without a sense of urgency. Closed reduction is ideally performed within 5 to 10 days postinjury.
- Patients should always be warned of the possibility of residual deformity and the need for secondary surgery before undergoing a closed reduction.
- Photographic documentation is helpful both as an accurate reminder of the preoperative state and to support the claim for future surgery should that be necessary.
- Indications for surgery include a septal hematoma or abscess (emergent), change in appearance, and change in breathing. If breathing is the only issue, and there is no appreciable change in appearance, this may be due to residual congestion or swelling from the injury, and little is lost in waiting. Delayed septal surgery does not present the same degree of challenge as the delayed treatment of a crooked nose.
- Closed reduction is best performed under intravenous sedation or general anesthesia. Maximal patient comfort will make it easier to forcefully manipulate the nasal bones if necessary and optimize the chances for a successful reduction.
- The nose should be suctioned out and topically decongested. An Asch septal forceps, carefully introduced on both sides of the septum under the nasal bones, gives the surgeon excellent control of the entire nasal pyramid. The fractured and displaced nasal bones are then disimpacted (which often means initially continuing movement in the direction of the initial force of the injury) and repositioned to the midline.
- If there remains a focal unilateral lateral nasal wall depression, this can be repositioned using the Boies elevator (Goldman elevator) placed directly under the bone in question.
- Packing is not routinely used, but it is recommended for the very comminuted or unstable reduced nasal fracture. Rolled Telfa coated in an antibiotic ointment is much more comfortable for the patient. The nose may be packed from 1 to 5 days, depending on the degree of perceived instability.
- An external splint is not absolutely necessary, but it will often discourage the patient from palpation or manipulation of the nasal framework and is thus recommended for 5 to 7 days.
Full coverage of the entire range of rhinoplasty principles and procedures is beyond the scope of this chapter. Instead, this chapter will focus on rhinoplasty fundamentals and the more common problems encountered, such as profile alignment, enhancement of nasal tip definition, and effecting changes in tip projection and rotation.
- Preoperative photographic documentation is essential. Standard facial views include a full frontal, right and left oblique, right and left lateral, and nasal base view. Close-ups are optional.
- Informed consent should include the risks of bleeding, intranasal scarring, worsening of the nasal airway, palpable or visible irregularities, asymmetry, failure to meet patient expectations, and the possible need for future revision surgery.
- Surgery may be performed under local anesthesia, intravenous sedation, or general anesthesia, depending on patient and surgeon preference. The latter two options are generally preferred.
- In all cases, the nose is also injected at the time of surgery with 10 to 15 cc of 1% lidocaine with 1:100,000 epinephrine for additional hemostasis, and decongested with either oxymetazoline or 4% cocaine (maximum 5 cc) soaked pledgets. The minimum amount of local anesthetic to facilitate hemostasis without overly distorting the nasal appearance is recommended.
- There is no absolute sequence for septal, tip, and dorsal surgery. It is more important to realize that all three are interrelated, and to understand and anticipate the impact that surgical maneuvers in one area may have on another.
There are basically two approaches to the nose: endonasal and external. The most important determinant here is physician comfort level and experience. In general, more typical indications for an external approach would include complicated revision surgery, unclear anatomy, severe asymmetry, the need for sutured-in-place grafting, the crooked nose, and the cleft lip rhinoplasty.
- Access to the dorsum is obtained by elevating the overlying skin and soft tissue envelope through bilateral intercartilaginous (IC) incisions (at the junction of the upper and lower lateral cartilages, ULCs and LLCs, respectively) connecting to a transfixion incision along the caudal septum. Midline dissection should remain in the avascular plane intimate to the perichondrium of the dorsal septum and deep to the periosteum of the nasal bones. Elevate the skin and soft tissue envelope (using an Aufricht or Converse retractor) only as much as is necessary for good exposure to facilitate reduction or augmentation, because the periosteal and soft tissue attachments to the nasal side wall help provide support and protect from excessive medial collapse of the nasal bones.
- Access to the nasal tip can be via IC incisions with retrograde dissection, or transcartilaginous (splitting the lateral crus of the lower lateral cartilage) incisions, but both of these imply more limited exposure/visibility and thus a higher risk of asymmetry. A third (and preferred) option if any significant tip surgery is planned endonasally is using an alar delivery approach, whereby the LLC is “delivered” or pivoted inferiorly through the nostril as a bipedicled chondrocutaneous flap (hinged medially and laterally) by combining IC incisions with a transfixion incision along the caudal septum (above the LLCs), and marginal incisions along the lower border of the LLC (below the LLC) on each side.
- An IC incision is made by everting the alar rim with a wide two-prong hook, at which point the caudal border of the ULC is apparent as a “shelf.” A no. 11 blade is then used to make an incision between the ULC and the overlying skin, parallel to the plane of the ULC, between the cephalic margin of the LLC and the caudal border of the ULC. This incision is then carried medially over the dorsal cartilaginous septum and around the anterior septal angle to connect with a transfixion incision along the caudal septum.
- The marginal incision is made by everting the alar rim and using a no. 15 blade to incise vestibular skin at the caudal border of the lower lateral cartilage, carefully following that border from lateral to medial, beneath the dome of the LLC and along the columella, taking care not to incise the caudal border of the medial crura in so doing. The overlying skin and soft tissue are then dissected from the LLC, which can be pivoted or “delivered” inferiorly by retracting the LLC downward with a small hook.
